12 July 2023
During a routine inspection
This service is rated as Requires improvement overall. (Previous inspection January 2019 – the service was found to be meeting the requirements of relevant regulations.)
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
Start this section with the following sentence.
We carried out an announced comprehensive inspection at Dr John Keet’s Consulting Room on 12 July 2023 as part of our inspection programme. Dr John Keet’s Consulting Room first registered with CQC in August 2015 and are registered for the regulated activities, treatment of disease, disorder or injury and diagnostic and screening procedures.
The registered manager is the individual provider and clinician for the company. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.
We reviewed 6 comment cards completed by patients in this year and found them all to be positive about the care and treatment they had received.
Our key findings were:
- The service provided care in a way that kept service users safe and protected them from avoidable harm, however gaps were identified in safety processes.
- Concerns identified and highlighted to the provider at the last inspection were identified again at this inspection.
- Some systems lacked oversight to ensure they were being adhered to and there were large gaps in the overall governance of policies and procedures and safety checks.
- Service users received effective care and treatment that met their needs.
- Service users were treated with kindness and respect and involved in decisions about their care.
- The service delivered services to meet service users’ needs. Service users could access care and treatment in a timely way.
We found a breach of regulation. The provider must:
- Ensure care and treatment is provided in a safe way to patients
The areas where the provider should make improvements are:
- Implement appropriate quality improvement activity for example, carrying out documented audits of activity such as prescribing and record keeping.
- Review the way that notes are stored so that all patient information is clear, orderly and accessible in a timely manner.
- Carry out risk assessments for those performing roles or duties within the service so that any associated risks are considered and documented.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Health Care